Permits 725 Atlantic Blvd # 3 City of Atlantic Beach
Building Department FDate
LICATION NUMBER
800 Seminole Road
ned by the Building Department.)
yr Atlantic Beach, Florida 32233-5445 _ �i�►
Phone(904)247-5826 - Fax(904)247-5845 v "
E-mail: building-dept@coab.us
City web-site: http://www.coab.us d: 7 /
APPLICATION REVIEW AND TRACKING FORM
Department review required Yes No
Property Address: /a� ��� l ��- �y� ui►din
ing &Zonin
I
Applicant: Al-S s/ Yl s Trministrator
Public Works
' !
Project: v (L) 0 0 al ry, Public Utilities n L Public Safety
Fire Services
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified B
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPLICATIPIN STATUS
Reviewing Department First Review: pproved. ❑Denied.
(Circle one.) Comments:
BUIL
PLANNING &ZONIN
TREE ADMIN. Reviewed by: Date:49/"0
PUBLIC WORKS Second Review: ❑Approved as revised. ❑Denied.
PUBLIC UTILITIES Comments:
PUBLIC SAFETY
FIRE SERVICES
Reviewed by: Date:
Third Review: ❑Approved as revised. ❑Denied.
Comments:
Reviewed by: Date:
CITY OF ATLANTIC BEACH
'r �-
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233
OFFICE:(904)247-5826•FAX NO.:(904)247-5845
BUILDING-DEPT@COAB.US
`` 1J BUILDING PERMIT APPLICATION DUVAL COUNTY
1.JOB ADDRESS: 2.VALUATION OF WORK: 3.SO.FT.UNDER ROOF
�'r 3�
4.LEGAL DESCRIPTION: 5.CLASS OF WORK: 6.USE OF STRUCTURE:
11 NEW BUILDING 11 DEMOLITION 11 RESIDENTIAL
LOT BLOCK SUBDIVISION .(}' C{� ('�.( 5 U��r ❑ADDITION CONVERTING USE COMMERCIAL
7.DESCRIPTION OF WORK: ❑ALTERATION C/�/SSORY BLDG. 6.FIRE SPRINKLER:
Wn !`fqqf r.. ft`/_� t .:: ¢w' ❑REPAIR ❑P / ❑YES ❑N/A
cl-I;l I w Gb t� t"b`YI �Y^S 1 Gtf'1114LL�- ❑MOVE OTHER®D ❑NO
PR OWNER: CONTRACTOR: ARCHITECT I ENGINEER:
9.NAME:A++�aa d 15.COMPANY NAM
Tf Q.i1ic. 't?ilfYiit./r 23.COMPANY NAME:
h,
16.NAME:`• 24.LICENSEE NAME:
flu >� 1�. '�Pki01� , -
10.ADDRESS: 17.STATE OF FLORIDA LICENSE NO.: 25.STATE OF FLORIDA LICENSE NO.:
!vu(4e 18.ADDRESS:^gyp �• J
-'---�� �l n r a6a3 J• �pC'�;�^J(i{� ��1 e 26.ADDRESS:
11.OFFICE PHONE: 12.FAX NO.: 19.OFFICE PHONE: 12,0.FAX NO.: 27.OFFICE PHONE: 28.FAX NO.:
c � <� z5-
13.CELL PHONE: 1.CELL PHONE: -
29.CELL PHONE:
14.EMAIL ADDRESS: 22.EMAIL AQ,DSS: 30.EMAIL ADDRESS:
r7ot1 5I 1
FEE SIMPLE TITLE HOLDER: ONDING CO PANY:
(IF OTHER THAN owNeR) MORTGAGE LENDER:
31.NAME: 33.NAME:
35.NAME:
32.ADDRESS: 34.ADDRESS:
36.ADDRESS:
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation has
commenced prior to the issuance of a permit and that all work will be performed to meet the standards of all laws regulating construction in this
jurisdiction. This permit becomes null and void if work is not commenced within six (6) months, or if construction or work is suspended or
abandoned for a period of six (6) months at any time after work is commenced. I understand that separate permits must be secured for
Electrical Work,Plumbing,Signs,Wells,Pools,Furnaces,Boilers,Heaters,Tanks, Air Conditioners,etc.
OWNER'S AFFIDAVIT-I certify that all the foregoing information is accurate and that all work will be done in compliance with all applicable
laws regulating construction and zoning. I will not occupy or use the referenced building or any part therof, until all inspections are finaled and
prior to obtaining a certificate of occupancy or completion issued by the building official,as required by law.
*** WARNING TO OWNER:
YOUR FAILURE TO RECORD A NOTICE OF COMMENCEMENT MAY RESULT IN YOUR
PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY. A NOTICE OF
COMMENCEMENT MUST BE RECORDED AND POSTED ON THE JOB SITE BEFORE THE
FIRST INSPECTION. IF YOU INTEND TO OBTAIN FINANCING, CONSULT WITH YOUR
LENDER OR AN ATTORNEY BEFORE RECORDING YOUR NOTICE OF COMMENCEMENT.
OWNERorAGENT CONT CTOR''
(If Agent,P er of Attorney or Agency Letter Required) (Q DIY)
Signed: Date: i 53 09 Signed: Date: 1 �county
Before a this� day of �Y1lxt! 20(F in the county of Before m is �day of Qn VQ 2001In t
Duval,State of Florida,has personally appeared Duval,State of Florida,has personally appeared
0 01I.-Al4in&nn &4
herin by himself/herself and affirms that all statements and declarations are herin by himself/herself a d affirms that all statements and declarations are
true and accurate. true and accurate.
Notary Public at Large,State of �I County of �Uyal Notary Public at Large,State of �) County of lVAJ
®/Personally Known L�YPersonally Known
❑Produced Identification- . ❑Produced Identification
Notary Signature: Notary Signature:
NOTARY PUBLIC-STA
•-,, Shari M. Fisher
Commission#DD775790 NOTARY PUBLIC-STATE OF FLORIDA
.;Expires: APR.06,2012 Shari M. Fisher
Bori>; �90IM5bo6 .Commission#DD775790
', ?.••`Expires: APR.06,2012
BONDED THRD ATLANLZC BONDING CO.,INC.
CITY OF ATLANTIC BEACH
800 SEMINOLE ROAD,ATLANTIC BEACH,FL 32233 08- -
OFFICE:(904)247-5826 0 FAX NO.:(904)247-5845
BUILDING-DEPT@COAB.US
ELECTRICAL PERMIT APPLICATION
1..losADDREss: DUVAL COUNTY
Z.IS THIS A SUB PERMIT: 3.DATE
3
❑NO W�oo� ��r/ /10
'; ) � � 11 YES PERMIT#:
PROPERTY OWNER:
4.NAME:
r { 5.A�DDDR/ESS IF DIFFERENT FROM JOB ADD ESS;
. ��' ` �1 .n 1 1 �1 1 16 t .'S `I�'I 7.� ..7 7 Sit �- 1 6.P�H}ONE:
U,va I 11. P1 il � t_�.�.. a vei'" I n {? ( � ��
ELECTRICAL CONT CTOR:
7.NAME OF COMPANY: 8.ADDRESS.:
Civs-5 �1S I� �� s�•c.L
J 'tl�^7�1�
9.STATE OF FLORIDA LI ENSE NO: 10.CELL PHONE:
CL- 11.FAX NO
12.EMAIL ADDRE ?`7
13.OFF CE PHO 14
15.Application is hereby made t6 obtain a permit to do the wor nd installations as indicated. I certify that all work will be performed to meet
the standards of all laws regulating construction in this jurisdiction. This permit becomes null and void if work is not menced within six(6)
months,or if construction or work is suspended or abandoned for a period of six(6)month a ny time ork' co enced.
CONTRACTORS SIGNATURE:
16.CLASS OF WORK: 17.SERVICE: 18.METER NUMBER: "
11 MULTI FAMILY-#OF UNITS: ❑RESIDENTIAL
❑SINGLE FAMILY ❑TEMP SERVICE 10 COMMERCIAL
❑ADDITION ❑TRAILOR 19.BUILDING: 19:CURRENT CODE: )
❑ALTERATION P SIGN ❑OLD ❑NEW ❑'05 NATIONAL ELECTRICAL CODE
❑REPAIR ❑POOL/SPA ❑REWIRE ❑OTHER:
LIST ALL ELECTRICAL WORK:
20.TYPE OF SERVICE: ❑ OVERHEAD ❑ UNDERGROUND ❑ UNDERGROUND UP POLE
21.NEW SERVICE: CONDUCTORS PER PHASE: ❑ POWER IS ON ❑ POWER IS OFF
22.SIZE OF CONDUCTOR: AMPACITY: ❑COPPER ❑ALUMINUM
23.SWITCH OR BREAKER SIZE: AMPS: PH: W: VOLT: RACEWAY SIZE:
24.EXISTING SERVICE SIZE: AMPS: PH: W: VOLT: RACEWAY SIZE:
25. FEEDERS: #OF AMPS: #OF AMPS: #OF AMPS:
26. LIGHTING FIXTURES: INCANDESCENT: FLUORESCENT&M.V.:
27.FIXED APPLIANCES: 0-30 AMPS: 31-100 AMPS: OVER 100 AMPS:
28. FIRE ALARM: ❑YES ❑ NO
29-31 DO NOT APPLY TO NEW SINGLE FAMILY,MULTI-FAMILY AND ROOM ADDITIONS
29.SMOKE DETECTORS: NUMBER:
30.RECEPTACLES: 0-30 AMPS: 31-100 AMPS: OVER 100 AMPS:
31.SWITCHES: 0-30 AMPS: 31-100 AMPS: OVER 100 AMPS:
32.AIR CONDITIONING:
#OF UNITS: COMP. MOTOR HP RATING: AMPS: HEAT KW:
#OF UNITS: COMP. MOTOR HP RATING: AMPS: HEAT KW:
33.MOTORS:
NUMBER: VOLTAGE: HP: KVA:
NUMBER: VOLTAGE: HP: KVA:
34.TRANSFORMERS:
UNDER 60OV: NUMBER: KVA:
OVER 60OV: NUMBER: KVA:
35.MISCELANEOUS REPAIRS:
DESCRIBE IN DETAIL:
COAG FORM BLDG02:REVISED:1/10/2008
✓4N �8
LETTER OF AUTHORIZATION
AFFIDAVIT
To Whom It May Concern,
This letter authorizes CNS SIGNS, INC. (or their Agents or Sub-Contractors)to act as
Agent to secure permits or variances required by local governing body, and to perform
sign and/or awning installations, removals, or maintenance at the property located at:
S' re o wrier uthorized Agent
112 Y'V"2
Printedarae of Owner/Authorized Agent
--------------------------------------------------
NOTARY
State of Florida
County of Duval
Sworn d subscribed before e his day of t!,ln QUC- 20
C-
MM
SigQnature of Notary*-State of rida
( )k Q{I 1 • t i ^5Lj�r
Print or Type Commissioned Name of Notary Public
Personally Known: [v'] Or Produced Identification: [ ]
Type of Identification Produced: Commission Expires:
NOTARY PUBLIC-STATE OF FLORIDA
Shari M. Fisher
i:Commission#DD.775790
,F Expires: APR.06,2012
BONB&D T
IWATLANTIC BONDING CO.,INC
City of Atlantic Beach APPLICATION NUMBER
�Yy
Building Department (To be assigned by the Building Department.)
�P, 800 Seminole Road
y� Atlantic Beach, Florida 32233-5445
Phone(904)247-5826 • Fax(904)247-5845 9
J31� E-mail: building-dept@coab.us Date routed: Q/
City web-site: http://www.coab.us �z
IL
APPLICATION REVIEW AND TRACKING FORM
D epaLment review required Yes No
a��cJ uildin
Property Address: IVing &Zonin
Applicant:
Tr mmistrator
/U-S 5 I n S Public Works
Public Utilities
Project: 6 of r,-n S nA440, Public Safety
Fire Services
Other Agency Review or Permit Required Review or Receipt Date
of Permit Verified B
Florida Dept.of Environmental Protection
Florida Dept.of Transportation
St.Johns River Water Management District
Army Corps of Engineers
Division of Hotels and Restaurants
Division of Alcoholic Beverages and Tobacco
Other:
APPYdATION STATUS
Reviewing Department First Review: DdApproved. ❑Denied.
(Circle Comments:
BUILDIN
PLANNING&ZONING
w
TREE ADMIN. Reviewed by: Date:
PUBLIC WORKS Second Review: ❑Approved as revised. ❑Denied.
PUBLIC UTILITIES Comments:
PUBLIC SAFETY
FIRE SERVICES
Reviewed by: Date:
Third Review: []Approved as revised. ❑Denied.
Comments:
Reviewed by: Date: